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• Nie I of x omrv& Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this fort to report results for all components tested. The completed form,written test procedures,and printouts from tests(if applicable),should be provided to the facility ownerfoperator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Chevron Bate of Testing: 10/28/08 Facility Address: 508 Charter Way, Stockton, CA 95206 Facility Contact: Maria I Phone: (209) 465-9440 Date Local Agency Was Notified of Testing: 09/30/08 Name of Local Agency Inspector(if present during testing): Ray 2. TESTING CONTRACTOR INFORMATION Company Name: EPIC Compliance Systems, Inc. Technician Conducting Test: Keith A. Huston #5262044-UT Credentials: ©CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: A License Number:880430 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Not Repairs Not Repairs, Component Pass Fail Tested Made Component Pass Fail Tester! Made Tank 1. Annular o a ❑ ❑ 7/$ UDC EI ❑ ❑ ❑ Tank 2 Annular 0 © ❑ ❑ ❑ ❑ ❑ Q Tank 3 Annular o ❑ ❑ ❑ o ❑ o ❑ Tank 1 Sec. Piping 0 a ❑ ❑ ❑ ❑ L ❑ Tank 2 Sec. Piping Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ Tank 3 Sec. Piping ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ Tank 1 Sump ❑ T1 ❑ ❑ j ❑ Ll ❑ Tank 2 Sum ❑ o ❑ ❑ ❑ ❑ ❑ ❑ Tank 3 Sump o ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1/2 UDC El ❑ ❑ ❑ ❑ ❑ ❑ ❑ 3/4 UDC El -u—Fa- ❑ ❑ ❑ ❑ ❑ 5/6 UDC I ❑ I Lj ❑ ❑ ❑ Ll Ll If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Date: 10/2$/[18 Technician's Signature: